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Psychiatric Provider Agreement

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Psychiatric Provider Agreement Powered By Docstoc
					                                 SIMS Foundation, Inc.  P.O. Box 2152 Austin, TX 78768
                                        Confidential Numbers: Phone 512-494-1007
                                                    Fax 512-542-9965
                                                  www.simsfoundation.org



             SIMS AGREEMENT FOR PSYCHIATRIC PROVIDERS

I, ______________________________________________, agree to be a provider of
psychiatric services for the SIMS Foundation, Inc.
* I understand that SIMS is a 501(c)(3) (non-profit) organization and that I am not
providing services as an employee of SIMS.
* I agree to abide by all of the terms and conditions provided in the Policies for SIMS
Psychiatric Providers, which I have read and understand.
* I agree at all times to maintain my professional licensure and liability insurance in
accordance with the Policies for SIMS Psychiatric Providers.
* I agree to uphold the ethics and standards of the licensure under which I practice.
* I further understand and agree that my compensation for the services I provide will be
as stated in the SIMS Psychiatrist Services Fee Schedule shown below.
                        SIMS PSYCHIATRIC SERVICES FEE SCHEDULE
Category of Visits           Patient Co-          SIMS Co-Pay               TOTAL
                             Pay                                            Reimbursement
                                                                            to Psychiatric
                                                                            Provider
Initial Psychiatric          Co-Pay   from $25 Balance remaining   after          $125
Assessment (APRN)            to $40            client co-pay
30 Minute Medication         Co-Pay   from $25 Balance remaining   after          $62.50
Management (APRN)            to $40            client co-pay
Initial Psychiatric          Co-Pay   from $25 Balance remaining   after           $200
Assessment (MD)              to $40            client co-pay
50 Minute Medication         Co-Pay   from $25 Balance remaining   after           $150
Management (MD)              to $40            client co-pay

______________________________                      __________________________________
Emily Rudenick, LPC                                 Signature of Psychiatric Provider
SIMS Clinical Director

__________________________                          _____________________________
Date                                                 Date
SIMS Agreement-Psychiatric Providers 10-09 .doc                            Page 1 of 2
SIMS Agreement-Psychiatric Providers 10-09 .doc   Page 2 of 2

				
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